A Strategy to Preserve Family Integrity, Promote Patient and Family Centered Care and Simultaneously Support a Safe Hospital Environment for Overnight Visitation

The importance of family presence and participation in the care of a hospitalized loved one is well established in the literature. Patient and family centered care has been adopted as a mechanism to promote family integrity and maintain wholeness of the family unit. Many studies have evaluated the importance and positive aspects of visitation in the hospital environment. Despite a preponderance of evidence, many nurses continue to view visitation as problematic. The most problematic timing of visitation is overnight and during procedures and resuscitation. Studies show mixed findings related to family presence during procedures and resuscitation however, no study was found that examined the issues of overnight visitation. Christiana Care Health System (CCHS), a 900-bed health system and level one trauma center has adopted patient and family centered care (PFCC) as a model of care delivery. Implementation of the PFCC model resulted in removing restrictions from family visitation. Visitors are welcome all hours of the day and night. This created problems of staff perceptions of safety and concern for privacy and confidentiality.  There have been situations of disruptive family members threatening nurses.  There are fewer resources available in the hospital in the evening and overnight to assist staff in dealing with disruptive visitors.  The health system cares for patients that have been victims of violence. Situations have arisen when perpetrators have come into the hospital seeking their victims and created significant disruption in care and safety.  Additionally, there have been situations of visitors providing patients with illicit substances that have contributed to patient harm.

CCHS adopted a policy of unrestricted visitation hours on inpatient care units, as part of PFCC in 2011. The health system administration recognizes concerns for staff and patient safety. Therefore, a strategy has been designed to improve security using visitor identification software and badges for visitation after 9PM and overnight. Prior to implementing the strategy, nurses were surveyed to identify concerns about overnight visitation. Results from this survey will augment an educational initiative planned as part of the technology implementation to address concerns discovered in the survey. Additionally, a family and visitor education pamphlet will be developed to describe expected behavior for overnight visitation.

The purpose of the study is to investigate the impact of a visitor badging system on nurse perceptions of safety as it pertains to overnight visitation, patient satisfactions, family and/or visitor complaints to patient relations, and visitor- employee violence encounters.

 An investigator-designed survey was electronically administered to volunteer staff nurses throughout CCHS over a 30-day period.  Survey results will be used to develop education in collaboration with the hospital system staff education specialists that will be made available on the system’s Education Center portal. This educational material will be launched congruent with commencement of the pamphlet release and badging program launch. The investigator-designed survey will be then be re-administered to volunteer staff nurses throughout CCHS approximately three months post implementation of the software program.

Principal findings of the initial survey are from 666 nurses representing a 33% response rate.  84% of respondents reported supporting allowing one adult family member to stay overnight with their hospitalized loved one in a private room, but only 19% of respondents expressed support for allowing one adult family member to stay overnight with their hospitalized loved one staying in a semi-private room. 50% of respondents reported that they are either comfortable or somewhat comfortable with overnight visitation.

66% of respondents reported that their opinions and perceptions about overnight visitors were informed by personal negative experience, while 33% reported being influenced by personal positive experience. 39% of respondents reported that colleagues’ experiences (30% positive and 9% negative) were influencing their views and opinions about overnight visitors. Only 12% of respondents reported basing their views and opinions about overnight visitation on information from clinical literature. 

82% of respondents reported concerns about difficult family members during overnight visitation, 75% reported concerns about patients getting adequate rest, 74% reported concerns about issues of privacy and confidentiality for roommates, 72% reported concerns about family impeding the provision of patient care, 60% reported safety concerns, 45% reported concerns about patient privacy and confidentiality, 44% reported being concerned about negative clinical impact on the patient and 40% of respondents reported concerns about visiting family getting adequate rest.

Whether a nurse had personal experience with overnight visitors for their patients did not significantly impact their support of overnight visitors for their patients in either a private room (p=0.06) or a semi-private room (p=0.19), nor did nurses’ tenure (p=0.63 and p=1.00) or gender (p=0.85 and p=0.29). However, respondents’ positions significantly impacted their opinions about overnight visitation, with non-bedside nurses (assistant nurse managers, nurse managers, nursing coordinators and nurse educators) having significantly more positive views about overnight visitors in both private rooms (p<0.01) and semi-private rooms (p<0.01) as compared to bedside nurses. Nursing opinion also varied significantly by specialty, with medicine and women’s and children’s services nurses reporting significantly more positive views about overnight visitors in private rooms (p<0.01 and p=0.01). Conversely, critical care nurses reported significantly less support for overnight visitors in private rooms (p<0.01). For overnight visitation to patients in semi-private rooms, stepdown unit nurses were significantly more positive (p=0.03) and surgical nurses were significantly more opposed (p=0.03) than colleagues in other specialty areas.

Nurses historically believed that without restrictions, family members would feel obligated to remain at the bedside. Family concerns focus on the desire to be physically with the patient to enhance emotional support. Opportunities to help care for the patient decrease family’s feelings of helplessness and lack of control.  Traditionally, nurses feared negative physiological impact of visitation on patients; however, current evidence indicates unrestricted visitation promotes patient stress reduction, a state of calmness, and promotes patient rest.   Designing nursing interventions to help families function during a crisis is a primary nursing practice issue. Supporting overnight visitation is a nursing intervention to aid patients in healing and promote family integrity. With implementation of these patient and family centered initiatives, staff concerns for safety cannot and should not be compromised.  This initial data demonstrates that nurses have a range of concerns about overnight visitors that should be addressed in overnight visitation policy.